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AIR  SERVICE 
MEDICAL  MANUAL 


WAR  DEPARTMENT    :     :    AIR  SERVICE 

DIVISION  OF  MILITARY  AERONAUTICS 

WASHINGTON,  D.  C. 


WASHINGTON 

GOVERNMENT  PRINTING  OFFICE 

1918 


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CONTENTS. 


PART  I. 

Page. 

Chapter  I. — Aviation  and  its  medical  problems 7 

II. — The  selection  of  the  flier 17 

III.— The  classification  of  the  flier 23 

IV. — The  maintenance  of  the  efficiency  of  the  filer 29 

(3) 


PREFACE. 


In  each  of  the  countries  at  war  there  is  a  fully  established  Air 
Medical  Service.  Early  in  the  development  of  the  Aviation  Service 
of  our  Allies,  and  even  earlier  in  the  German  Air  Service,  it  was 
found  essential  to  create  a  medical  department  as  an  integral  part  of 
the  Air  Force.  The  French  and  the  Italians  for  the  past  year  have 
had  well-organized  Air  Medical  Services,  which  include  in  their 
personnel  many  of  the  foremost  specialists  of  these  respective  coun- 
tries. The  British,  whose  Koyal  Air  Force  exists  as  a  separate  arm 
of  the  service,  have  a  separate  Air  Medical  Service  with  a  Surgeon 
General  of  Aeronautics.  *  In  our  own  Service,  this  work  has  been 
effectively  handled  by  a  division  of  the  Surgeon  General's  Office, 
assigned  as  a  part  of  the  Division  of  Military  Aeronautics. 

Aviation  is  new,  and  the  Air  Medical  Service  even  newer;  so  that 
for  educational  purposes  the  director  of  Military  Aeronautics  deemed 
it  advisable  to  issue  this  book.  Its  object  is  to  set  forth  Aviation's 
debt  to  Medicine  and  to  make  clear  the  part  played  by  the  Air 
Medical  Service  in  the  "  winning  of  the  war  in  the  air." 

The  book  is  presented  in  two  parts.  Part  I  is  a  shorter  statement 
of  the  essential  facts  which  are  of  immediate  general  interest.  Part 
II  goes  into  greater  detail  and  is  for  the  information  of  those  who 
belong  to  the  Air  Medical  Service  or  of  those  who  desire  to  make  a 

more  thorough  studv  of  this  new  work. 

15) 


7a 


PART  I. 


CHAPTEK  I. 
AVIATION  AND  ITS  MEDICAL  PROBLEMS. 


Wonderful  has  been  the  development  of  the  airplane-mconceiv- 
able  has  been  the  neglect  of  the  MAN  in  the  airplane. 

Aviation  began  in  the  United  States  of  America.    The  gemus  ot 
Lang    y,  Chanute,  and  the  Wright  brothers  made  it  possible  to  ma  n- 
tain  in^he  air  a  machine  heavier  than  air.     Startmg  as  a  scien   fie 
experiment,  aviation  has  developed  with  such  gigantic  strides  that 
L- da">  the  defense  of  our  Nation,  the  Air  Force  has  a  place  com- 
parable in  fighting  importance  with  the  land  and  ^^^  f^^^^, 
^  Ever  since  the  time  that  man  lived  m  a  cave  and  was  obliged  to 
chase  his  food  or  be  chased  by  it,  he  has  dreamed  of  flying     He  has 
racked  his  brain  and  bruised  his  body  in  futile  attempts  to  emulate 
the  bird.     At  various  stages  in  his  history  we  see  him  climbing  to   he 
top  of  precipices,  trees,  bridges  and  houses,  and  from  these  heights 
projecting  himself  into  space,  with  nothing  to  break  his  fal   except  a 
modified  kite,  parachute,  or  some  similar  contrivance,  and  landing 
below  with  many  regrets  and  broken  bones.     Gravitation  was  not  to 
be  defied  by  such  rudimentary  methods. 

Through  all  time  man  has  been  speeding  up.     The  savage  finding 
himself  upon  a  snow-capped  height  and  desiring  to  go  to  the  valley 
below,  was  wont  to  set  himself  upon  a  piece  of  bark  and  slide  down 
to  his  destination;  or,  desiring  to  go  down  the  valley,  he  stepped  into 
a  hollow  log  and  shot  the  rapids  of  some  swiftly  flowmg  stream. 
Desiring  to  cross  the  plain,  he  subjugated  the  horse  and  used  him  as 
a  more  rapid  means  of  transportation.     Later  on  civilized  man, 
astride  a  pair  of  wheels,  propelled  himself  along  the  highway  by 
means  of  a  mechanical  device.     Then  the  steam  engine  was  invented, 
and  with  it  the  steamboat  and  locomotive,  which  enabled  man  to 
travel  with  increased  speed.    The  electric  trolley  car  appeared  soon 
after  the  perfection  of  the  electric  motor.     Eventually  came  the  gas 
en-ine,  and  with  that  the  automobile,  capable  of  even  greater  velocity. 
It  Is  not  surprising  that  in  the  United  States,  the  least  mature  of  the 
progressive  nations  of  the  world,  this  speed  mania  broke  all  bounds 


8 


AIR   SERVICE   MEDICAL   MANUAL. 


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10  AIR  SERVICE   MEDICAL  MANUAL. 

and  man  flew  off  at  a  tangent  into  space.  The  Wright  airplane  had 
set  a  new  pace. 

Each  new  mode  of  travel  has  evolved  its  own  new  and  peculiar 
human  ills  and  medical  problems.  Reverting  to  the  savage,  we  can 
picture  a  new  variety  of  accidents  coincident  with  rudimentary 
tobogganing.  With  water  transportation  came  seasickness  and 
drowning,  with  the  various  methods  of  resuscitation.  Railroading 
developed  a  new  category  of  ills,  from  caisson  disease  to  "  railroad 
spine ;  "  railroad  signaling  emphasized  the  importance  of  normal 
color  perception.  With  the  development  of  the  electric  railway 
there  opened  up  a  new  chapter  of  ills  in  the  form  of  electric  shocks 
and  burns.  With  the  gas  engine  came  Colle's  fractures  from  crank- 
ing and  an  increasing  number  of  collision  accidents  with  the  ever- 
increasing  speed.  Now  with  the  airplane  come  the  new  problems  of 
air-sickness,  oxygen-want,  and  the  unprecedented  demands  on  the 
special  senses,  the  nervous  system,  and  the  heart. 

While  American  genius  made  possible  the  birth  of  the  airplane, 
its  extraordinary  development  in  such  a  short  space  of  time  is  di- 
rectly due  to  the  drive  of  necessity  arising  from  actual  warfare  in 
Europe.  Prof.  Langley's  theories  of  heavier-than-air  machines  were 
correct ;  the  producers  of  airplanes  have  converted  them  into  realities. 
After  the  appearance  of  the  Wright  biplane,  however,  flying  in  this 
country  made  little  progress ;  we  Americans  were  slow  to  appreciate 
the  possibilities  of  this  new  invention.  The  Wright  brothers  took 
their  machine  to  Europe,  where  an  immediate  keen  interest  developed 
in  its  sporting  possibilities,  which  appealed  particularly  to  the 
French,  Italians  and  English.  The  German,  ever  watchful  of  any- 
thing calculated  to  enhance  the  value  of  his  war  equipment,  immedi- 
ately took  notice  and  began  airplane  experiments.  Thus  the  French, 
Italian  and  English  interest  had  its  root  in  the  appeal  of  the  plane 
to  sporting  instinct ;  the  German  interest,  on  the  other  hand,  sprang 
from  "  Kultur,"  in  recognition  of  its  possibilities  as  an  additional 
weapon  of  war.  The  development  of  the  airplane  among  the  Allies 
is  a  story  of  sportsmanship;  among  the  Germans  it  is  part  of  the 
secret  annals  of  war  preparation.  During  the  early  stages  of  the  war 
air  superiority  lay  with  the  Germans  and  was  represented  mainly 
by  their  development  of  the  Zeppelin.  During  this  period  the  Ger- 
mans placed  their  trust  in  the  lighter-than-air  type  of  machine;  at 
the  same  time  they  did  not  neglect  the  heavier-than-air  type.  It 
was  not  until  1916  that,  under  the  spur  of  war  conditions,  both  bel- 
ligerents came  to  a  full  realization  of  the  immense  possibilities  of  the 
airplane  as  a  factor  in  battle.  It  is,  therefore,  the  other  nations  who 
have  developed  the  airplane,  and  we  now  look  to  these  nations  for 
advice  and  instruction  in  aeronautics ;  it  is  a  case  of  the  pioneer  tak- 
ing the  position  of  a  novice  in  his  own  field  of  endeavor. 


LANGLEY  STEAM-DRIVEN  AERODROME   IN  FLIGHT   OVER   POTOMAC   RIVER  NEAR    QUANTICO,  VA., 

,       „  MAY  6,  1896. 

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QUARTER-SIZE  GASOLINE  MODEL,  LANGLEY  AERODROME,  IN  ONE  OF  ITS  FLIGHTS  OF  AUGUST  8,  1903, 

ON  THE  POTOMAC  RIVER. 

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CADET  APPROACHING  PLANE  WITH  INSTRUCTOR  ON  HIS  FIRST  TRIP.     THE  CADET 

IS   MERELY   A    PASSENGER. 


A  CADET  AND   HIS  INSTRUCTOR. 


INSTRUCTOR  IMPRESSING  UPON  THE  CADET  THE  USE  OF  THE  RUDDER. 


CADET   AND   INSTRUCTOR   IN   THE    MACHINE. 
The  instructor  is  assisting  tlie  cadet  who  is  experiencing  an  air  trip  for  tlic  first  time. 


lOa-10 


CADET  RECEIVING  FINAL  INSTRUCTIONS  BEFORE  GOING  ON  A  FLIGHT  ALONE. 
This  cadet  has  completed  his  preliminary  course  and  is  about  to  start  on  a  solo  flight. 


lOa-11 


STARTING   OFF   ON  A   FLIGHT. 


PILOT  AND  CADET  SLOWLY  AND  CAREFULLY  DESCENDING  TO  A  LANDING  PLACE. 


lOa-12 


CADET  DESCENDING   FOR  HIS  FIRST  LANDING. 


CADET    EXPERIENCES    FIRST   HALF    HOUR    IN    AN   AIRPLANE. 
The  instructor  made  a  perfect  landing  without  bumping,  much  to  the  satisfaction  of  the  student. 

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A  CADET   READY   FOR   HIS   FIRST   SOLO   FLIGHT. 


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A  CADET  AFTER  HIS   FIRST   SOLO   FLIGHT. 
Having  had  his  first  ride  he  smiles  all  over  upon  landing. 


\ 


AIR  SERVICE   MEDICAL  MANUAL.  11 

It  is  easy  to  see  how  the  necessity  for  attention  to  the  physical 
efficiency  of  the  pilot  came  to  be  overlooked ;  the  world  over,  everyone 
has  been  so  absorbed  in  the  one  effort — to  increase  the  mechanical 
efficiency  of  the  airplane.  Every  thought  has  been  directed  toward 
making  each  successive  model  safer  and  faster. 

During  this  period,  representing  the  first  two  and  one-half  years 
of  the  war,  the  pilot  was  not  selected  because  of  any  peculiar  fitness 
for  flying;  it  was  simply  a  question  of  whether  he  "  had  the  nerve." 
At  one  time  circumstances  made  it  necessary  to  place  men  in  the 
Aviation  Service  who  were  "  all  worn  out  by  the  more  trying  work  " 
of  the  Infantry  or  Field  Artillery.  The  viewpoint  was :  "  This  man 
is  no  longer  fit  for  ground  fighting;  therefore  he  will  do  for  the  air 
service."  The  result  of  this  policy  was  that  the  average  aviator  had 
a  very  short  time  of  usefulness  and  there  was,  to  this  extent,  some 
truth  in  the  persistent  rumor  that  the  "  active  life  of  the  aviator  at 
the  front  was  only  a  certain  number  of  hours."  There  was  enormous 
avoidable  wastage.  Little  by  little  the  Aviation  Services  of  our  Allies 
have  come  to  realize  that  the  advice  of  their  medical  officers  was 
sound;  the  mental  and  physical  requirements  for  entering  the  Air 
Service  were  raised,  with  an  immediate  saving  of  an  unlimited 
amount  of  money  and  personnel.  This  is  the  great  lesson  we  have 
learned  from  the  bitter  experience  of  our  Allies. 

The  popular  idea  that  a  flier  must  be  a  "  superman  "  is  utterly 
absurd.  It  would  be  much  nearer  the  truth  to  say:  "Anyone  can 
fly."  Flying  itself  is  now  just  as  prosaic  and  commonplace  as  riding 
in  a  motor  car,  and  not  more  dangerous.  To  consider  that  the  aviator 
at  the  front  is  in  greater  danger  than  his  brother  in  the  trenches  is 
ridiculous ;  actual  statistics  prove  that  it  is  far  safer  in  the  air.  Fur- 
ther than  this,  instead  of  living  in  the  filth  of  the  trenches,  the  fight- 
ing pilot  returns  to  a  comfortable  airdrome  well  behind  the  lines, 
where  he  sleeps  in  comfort  and  one  might  even  say  in  comparative 
luxury. 

Nevertheless,  aviation  is  not  merely  spectacular;  it  does  have  its 
unique  problems  and  makes  its  unique  demands  upon  those  in 
this  service.  Nature  never  intended  that  man  should  fly.  From  the 
time  that  he  leaves  the  ground  until  his  return,  he  is  living  under 
unnatural  conditions.  Although  it  should  be  emphasized  again  and 
again  that  the  flier  at  the  front  is  safer  than  the  infantryman  in  the 
trenches  this  does  not  mean  that  we  should  belittle  the  conditions 
which  the  aviator  faces.  He  flies  in  an  atmosphere  lacking  in  that 
oxygen  which  is  the  "  breath  of  life  " ;  subjected  to  the  shells  of  anti- 
aircraft gims,  or  encountering  enemy  aircraft  at  any  moment;  with 
his  body  at  a  dizzy  height  and  hurtling  through  space  at  the  rate 
of  125  miles  an  hour— this  represents  the  daily  life  of  the  fighting 


12  AIR  SERVICE   MEDICAL  MANUAL. 

pilot.  The  aviator  himself  is  serenely  unconscious  of  the  effect  of 
these  conditions  upon  his  nervous  system;  he  naturally  regards  it 
as  "  all  in  a  day's  work."  Yet  in  attaining  altitudes  and  spending 
much  of  his  time  in  rarefied  air,  the  flier  is  defying  nature. 

The  conquest  of  the  air  represents  man's  maximum  achievement. 
There  is  no  combination  of  wood  and  wire  which  is  subjected  to 
such  a  variety  and  intensity  of  strain  and  stress  as  the  airplane; 
there  is  no  living  combination  of  muscle  and  nerve  which,  consciously 
or  unconsciously,  may  be  subjected  to  such  a  variety  and  intensity  of 
strain  and  stress  as  the  aviator. 

To-day  thousands  of  trained  mechanics  are  working  day  and  night 
upon  the  engines  of  our  airplanes ;  thousands  of  expensively  trained 
riggers  and  sailmakers  are  tuning  the  wires  and  mending  torn  fabric ; 
thousands  of  hangars  are  provided  to  house  the  planes  when  they 
are  not  flying.  A  striking  discrepancy  is  noted  when  we  look  about 
to  see  what  is  being  done  to  take  care  of  that  infinitely  more  delicate 
organism — the  man  who  flies  the  machine. 

The  pilot  of  the  airplane  is  the  heart  and  brain  of  the  whole  flying 
apparatus.  The  engine  may  fail  through  lack  of  care,  but  the  pilot 
brings  the  machine  safely  back  to  the  airdrome.  A  carelessly  inspected 
wire  may  snap  in  the  air,  but  nothing  serious  results.  When  the 
pilot  breaks,  even  momentarily,  nothing  is  left  to  direct  the  flight, 
and  the  plane  and  engine,  no  matter  how  well  they  have  been  cared 
for,  crash  and  are  lost. 

The  mechanic  who  looks  after  the  troubles  of  the  engine  must  be 
an  expert.  Work  like  this  is  not  for  the  mediocre.  No  less  an  expert 
must  be  that  man  who  supervises  the  condition  of  the  pilot.  Flying, 
especially  in  the  military  service,  coupled  with  the  temperament 
peculiar  to  the  man  choosing  this  kind  of  work,  develops  a  most  ex- 
traordinary series  of  problems  and  complications.  Many  an  aviator 
in  a  short  time  becomes  a  subject  over  which  a  genius  in  medicine 
might  easily  become  discouraged. 

The  establishment  by  our  forefathers  of  the  West  Point  Military 
Academy  was  a  wise  forethought.  In  this  institution  a  curriculum  of 
four  years'  intensive  study  prepares  our  young  men  for  the  profession 
of  the  soldier.  In  this  war,  however,  an  important  and  novel  military 
situation  has  arisen;  even  West  Point  does  not  offer  a  solution  of 
this  problem.  The  Air  Fighting  Force  is  without  military  precedent 
to  furnish  instruction  in  all  its  details.  The  problems  of  this  war 
on  the  ground,  while  new  in  many  aspects,  still  could  be  met  by  the 
skill  of  the  engineer  and  the  tactician  with  fundamentals  furnished 
by  years  of  military  experience  and  study.  The  problems  of  the  pres- 
ent war  in  the  air  lack  the  accumulated  experience  of  previous  wars 
to  indicate  their  solution;  those  difficulties,  which  early  made  it 
apparent  to  our  Allies  that  an  air-fighting  force  has  its  own  poten- 


AIR  SEEVICE   MEDICAL  MANUAL.  13 

tialities  of  disaster,  presented  the  immediate  problems  of  our  Air 
Service. 

To  the  Air  Medical  Service  the  problems  were  presented  of  over- 
coming all  those  conditions  aifecting  the  physical  fitness  of  the  man 
who,  leaving  his  natural  environment,  the  ground,  straps  wings  to 
his  body  and  soars  to  heights  into  which  even  the  eagle  dare  not  go. 
For  work  in  this  unnatural  environment  onlj^  the  man  who  is  in 
every  way  physically  fit  should  be  selected. 

When  our  Air  Medical  Service  was  established  it  was  fortunate 
to  have  at  hand  a  series  of  reports  of  the  Air  Medical  Services  of  our 
Allies  by  medical  officers  who  have  attained  distinction  in  the  field 
of  scientific  research.  Birley,  Dreyer,  Haldane,  Flack,  Douglas,  and 
Priestly  among  the  British ;  Nepper,  Josue,  Lombaert,  Guilbert,  Gar- 
saux  among  the  French;  Gradenigo  and  Herlitzka  among  the 
Italians,  had  been  studying  for  years  the  physical  deterioriations 
peculiar  to  flying  which,  even  early  in  the  war,  so  emphasized  the 
military  importance  of  this  particular  problem  of  the  Air  Service. 

The  keynote  of  the  American  Air  Medical  Service  is  the  handling 
of  the  flier  as  an  INDIVIDUAL. 

During  the  early  part  of  the  war  the  German  method  of  air  fight- 
ing was  patterned  after  that  of  their  infantry ;  the  pilot  of  the  ma- 
chine received  his  commands  and  carried  them  out  regardless  of 
changing  conditions.  The  observer  in  a  two-seater  machine  gave 
the  pilot  his  orders,  just  as  an  infantry  officer  gave  orders  to  his 
subordinate.  There  were  only  a  few  picked  flying  officers,  usually  of 
high  social  position,  who  were  what  might  be  called  "  sportsmen."' 
The  efficiency  of  the  German  Air  Service  was  greatly  increased  in  the 
3^ear  1917  by  their  allowing  a  certain  freedom  of  action  to  their  pilots 
in  order  to  cope  with  the  more  speedy  allied  air-men  who  had  proven 
individually  far  superior  in  action,  spirit  and  initiative.  Infantry 
and  cavalry  which  strike  in  large  numbers  must  be  handled  as  a  single 
force ;  they  must  have  coordination  and  absolute  oneness  of  action  or 
half  their  effectiveness  is  lost.  The  efficiency  of  such  troops  is  meas- 
ured by  the  successful  handling  of  a  large  striking  force  as  a  single 
unit.  The  aviator  is  the  rank  and  file  and  commanding  officer,  all  in 
one.  The  outcome  of  a  reconnaissance  flight  may  determine  the  fate 
of  thousands  on  the  ground;  but  it  is  the  flier's  individual  decision, 
initiative  and  action,  that  spell  victory  or  defeat  for  him. 

The  Air  Medical  Service,  devoted  as  it  is  entirely  to  the  study  of 
the  flier  as  an  individual,  naturally  falls  into  three  main  lines  of 
activity — the  Selection  of  the  Flier,  the  Classification  of  the  Flier,  and 
the  Maintenance  of  the  physical  efficiency  of  the  Flier.  These  three 
branches  of  the  Air  Medical  Service  are  presented  in  concise  form  in 
Part  I  of  this  book.  In  Part  II  is  given  a  fuller  discussion  of  these 
same  subdivisions. 


14  AIB  SERVICE   MEDICAL  MANUAL. 

Underlying  "  Selection  "  is  a  full  realization  that  it  is  possible  for 
a  man  to  fly  in  spite  of  one  or  many  handicaps;  the  object  to  be  at- 
tained, however — the  defeat  of  the  enemy — demands  that  only  such 
fliers  be  sent  against  him  as  are  the  very  best  air-fighting  material — 
not  merely  men  who  are  able  to  fly. 

"  Classification "  is  the  second  step.  The  flying  service  is  now 
highly  specialized.  Men  are  called  upon  to  perform  widely  diversi- 
fied classes  of  work,  such  as  pursuit,  reconnaissance,  photography, 
bomb-dropping  and  night-flying.  Not  every  aviator,  regardless  of 
perfect  training  and  physical  fitness,  is  necessarily  fitted  for  all 
types  of  air  activities.  There  is  a  marked  difference  in  the  individual 
ability  to  withstand  a  diminished  oxygen  supply;  this  has  made  it 
necessary  to  classify  the  fliers  on  an  altitude  basis.  By  means  of 
tests  applied  at  the  Medical  Research  Laboratory  at  Mineola,  Long 
Island,  and  at  the  branch  laboratories  in  the  various  flying  schools 
throughout  this  country  and  overseas,  fliers  are  being  classified  as 
fitted  for  low,  moderate,  and  high  altitudes,  night-flying,  and  other 
special  types  of  work. 

The  "Maintenance"  of  physical  efficiency  of  the  flghting  force  is 
the  supreme  function  of  the  Air  Medical  Service.  There  is  a  sharp 
contrast  between  the  work  of  selection  and  the  work  of  maintenance. 
In  selection  the  sole  object  is  that  all  questionable  material  be  kept  out 
of  the  service.  In  maintenance  the  great  object  is  that  every  aviator 
be  kept  in  r.he  service. 

When  an  airplane  begins  to  show  signs  of  trouble,  it  is  taken  off 
the  field  and  put  in  condition.  This  is  the  only  way  to  keep  a  plane 
in  commission.  When  the  flier  shows  the  first  signs  of  staleness,  of  nerv- 
ous exhaustion,  or  of  digestive  disturbance  he  must  be  "  overhauled  " 
by  a  medical  expert.  That  distinctly  American  product — the  Flight 
Surgeon — bears  the  same  relation  to  the  flier  that  the  mechanical  ex- 
pert bears  to  the  airplane. 

The  airplane  is  in  need  of  frequent  overhauling ;  the  flier  even  more. 
The  secret  of  prolonged  usefulness  of  any  aviator  is  that  he  be  kept 
constantly  fit.  The  Flight  Surgeon,  by  both  old  and  new  diagnostic 
methods,  supplemented  by  his  knowledge  of  the  peculiarities  of  the 
individual  flier,  is  able  to  detect  very  early,  the  signs  of  deterioration. 
The  corrective  measures  to  be  applied  will  belong  to  one  of  three 
classes.  They  are  medical,  physical,  and  what  we  may  term  nutri- 
tional. The  medical  needs  constitute  especially  the  problem  of  the 
Flight  Surgeon.  In  order  to  supplement  his  work  and  take  care  of  the 
physical  needs  of  the  flier,  there  have  been  secured  for  the  Aviation 
Service  the  services  of  experienced  college  trainers.  These  men  have 
been  given  a  course  of  instruction  covering  the  special  aspects  of 
physical  training  as  it  applies  to  the  care  of  the  flier,  and  have  then — 
as  Physical  Directors — ^been  sent  out  to  each  flying  field  to  assist  the 


AIR  SERVICE   MEDICAL  MANUAL.  15 

Flight  Surgeon.  These  Physical  Directors  fill  a  special  need  in  the 
work  of  "  maintenance  "  in  that  they  bring  to  this  service  the  practical 
experience  already  derived  from  the  handling  of  athletes  in  colleges 
or  athletic  clubs. 

In  order  to  handle  most  successfully  the  third  class,  namely,  nutri- 
tional problems,  the  services  of  the  Nutrition  Officer  are  required. 
The  Nutrition  Officer  must  be  a  man  well  trained  in  the  knowledge  of 
food  values  in  relation  to  the  body  and  he,  under  direction  of  the 
Flight  Surgeon,  is  charged  with  not  only  the  problem  of  the  proper 
feeding  of  the  normal  flier,  but  especially  of  the  flier  suffering  transi- 
tory digestive  disturbance — a  type  of  defect  that  affects  greatly  the 
efficiency  of  the  flier  when  in  the  air. 

The  work  of  the  Air  Medical  Service  reached  its  culmination 
with  the  placing  of  a  Flight  Surgeon  in  each  flying  school  in  the  United 
States  where  his  work  in  the  "  care  of  the  flier  "  has  been  but  a  prepa- 
ration for  the  larger  service  to  the  aviator  who  is  actually  on  the 
fighting  front  overseas.  It  is  only  through  the  complete  Flight 
Surgeon  Service,  including  those  features  supplied  by  the  Physical 
Director  and  the  Nutrition  Officer,  that  the  flier  may  be  maintained 
at  his  full  efficiency  in  active  service. 


CHAPTEE  II. 
THE  SELECTION  OF  THE  FLIER. 


When  it  was  announced  that  a  state  of  war  existed  between  the 
United  States  and  Germany,  it  at  once  became  apparent  that  a  tre- 
mendous number  of  aviators  must  be  secured  for  the  military  service 
within  the  shortest  possible  space  of  time.  The  medical  problem 
consisted  of  selecting  thousands  of  physically  acceptable  men  for  avia- 
tion and  placing  them  in  training  for  war  service  immediately. 

It  was  found  necessary  to  decide  upon  new  methods  of  physical 
examination  and  to  adopt  new  standards  of  physical  qualifications 
for  this  branch  of  the  .service.  Before  our  entrance  into  the  war  con- 
siderable thought  had  been  given  to  the  problem  of  what  should 
constitute  the  physical  requirements  for  admission  into  the  aviation 
service,  and  medical  officers  had  been  in  conference  with  other  mem- 
bers of  the  medical  profession  who  were  interested  in  this  question. 
Due  consideration  also  had  been  given  to  the  study  of  the  require- 
ments formulated  by  England,  France,  and  Italy,  and  also  Germany. 
The  examination  according  to  amended  blank  609,  A.  G.  O.,  was  put 
into  operation  in  May,  1917,  and  it  is  worthy  of  note  that  this  same 
series  of  tests  remains  unaltered,  even  to  the  minutest  detail,  up  to  the 
present  time. 

The  judgment  applied  to  the  original  selection  of  those  to  consti- 
tute the  Air  Fighting  Force  of  the  United  States  was  not  based  upon 
an  attempt  to  decide  whether  or  not  the  individual  selected  would  be 
able  to  fly.  It  was  known  that  men  had  been  able  to  fly  in  spit©  of 
one  or  more  physical  handicaps,  such  as  having  only  one  leg,  having 
one  eye,  having  tuberculosis,  or  being  cross-eyed,  or  having  one  col- 
lapsed lung,  or  being  well  over  50  years  of  age.  Instances  were  at 
hand  of  those  so  handicapped  who  had  been  able  to  learn  to  fly  and 
to  fly  well.  Ultimate  economy  as  well  as  immediate  efficiency  indi- 
cated unquestionably  the  wisdom  of  admitting  to  training  only  the 
very  best  material.  The  enormous  number  of  applicants  at  hand 
made  it  possible  to  maintain  the  highest  standards  in  selecting  men 
for  this  service.  It  had  been  demonstrated  by  the  experience  of  our 
Allies  that  careful  selection  would  avoid  the  expense,  in  time  and 
money,  of  training  large  numbers  of  those  who  would  not  make  good 
in  the  service.  Furthermore,  our  measuring  stick  was  chosen  in 
anticipation  of  peak-load  requirements.  It  was  realized  that  each 
man  entering  the  flying  service  might  be  called  upon  to  negotiate 
89120—18 2  17 


18 


AIR  SERVICE   MEDICAL  MANUAL. 


•m   -      »-=-:r^=-~ 


LOOPING.  ,   .    ,  ^    ,. 

Success  in  looping  impossible  if  the  aviator  has  any  "mental  twists. 


AIR   SERVICE   MEDICAL   MANUAL 


20  AIR   SERVICE   MEDICAL  MANUAL. 

critical  emergencies  in  the  air;  that  insufficient  oxygenation  coupled 
with  prolonged  nervous  tension  under  high  altitude  combat  condi- 
tions, actual  injury,  sudden  changes  in  circumstances  demanding  in- 
stant decision  and  action,  would  require  of  him  the  utmost  mental 
and  physical  capabilities. 

It  is  only  right  that  we  should  supply  for  our  air  fighters  as  good 
if  not  better  planes  than  those  used  by  the  enemy.  In  the  same  spirit, 
it  is  our  duty  to  bear  in  mind  that  when  an  American  aviator  meets 
a  German  aviator  the  outcome  of  the  encounter  may  easily  depend 
upon  which  of  the  two  possesses  the  better  vision  and  other  special 
senses,  the  better  nervous  system,  and  the  better  mental  and  physical 
equipment  in  general.  The  flier  starting  for  the  enemy's  lines  car- 
ries with  him  a  certain  potential  disaster  for  the  Hun.  The  one-eyed 
man  may  succeed ;  the  possession  of  tvro  eyes,  however,  would  render 
success  more  certain.  The  responsibility  of  the  Air  Medical  Service 
in  the  selection  of  the  flier  is  that  no  aviator  shall  fail  in  his  mission 
against  the  Hun  because  of  discoverable  physical  defect 

In  order  to  make  the  examination  of  standard  character,  it  was 
necessary  to  make  the  tests  practicable  of  application  in  all  parts  of 
the  United  States  without  at  the  same  time  in  any  way  lowering  the 
requisite  rigid  standards  or  lessening  the  completeness  of  the  exami- 
nation. This  could  be  attained  only  by  (1)  the  standardization  of 
the  tests  and  (2)  the  standardization  of  the  examiners.  •  To  accom- 
plish this,  a  medical  officer  was  sent  to  each  of  35  cities  throughout  the 
United  States,  with  the  result  that  in  each  one  of  these  cities  there 
vx^as  established  a  medical  unit  for  the  examination  of  applicants  for 
the  Aviation  Service.  The  requirements  of  the  examination  were 
fully  explained  to  each  unit,  so  that  not  only  the  same  equipment  was 
used,  but  also  exactly  the  same  technique.  This  made  it  impossible 
for  any  applicant  to  say,  "  I  wish  I  had  been  examined  in  a  certain 
city  where  the  tests  are  easy,  rather  than  in  a  certain  other  city  where 
the  tests  are  exacting."  Those  specialists  were  selected  who  were 
most  expert  in  the  practice  of  their  chosen  work;  where  a  new  type 
of  examination  was  essential,  such  as  the  turning-chair  tests,  those 
otologists  were  selected  who  were  familiar  with  these  tests,  and,  in 
addition,  they  were  given  intensive  training  by  medical  officers  sent 
for  the  purpose  of  establishing  a  uniform  technique.  Thus  in  a  fe"v^' 
months  the  examination  was  put  on  a  uniform  basis  in  all  Physical 
Examining  Units. 

In  order  to  save  time,  alreadj^  existing  institutions,  such  as  large 
hospitals  or  State  universities,  with  their  equipments,  were  utilized 
as  these  examining  centers.  Volunteer  staffs  of  civilian  consultants 
were  locally  organized  and  the  work  of  the  Physical  Training  Units 
systematized  to  a  point  of  highest  efficiency,  with  the  result  that 


JUST  MISSING  A  FLAGSTAFF. 

Prompt  action,  intelligently  executed,  saved  this  flyer  and  his  machine  from  a  crash.    Fighting  in  the  air 

makes  continual  demands  on  such  ability. 


MAKING  A  PERFECT  LANDING. 
This  requires  perfect  stereoscopic  vision. 


20»-X 


FIGHTING  IN  THE  AIR  MAKES  THE  MOST  SEVERE  DEMANDS  ON  PILOTS. 
Only  the  most  fit  are  chosen  for  this  work. 


CADET  AMONG  THE  CLOUDS. 

A  situation  in  which  vision  is  of  little  use.     The  "motion-sensing"  portion  of  the  interval  ear  must 

be  normal,  or  the  pilot  can'not  detect  movement  normally. 
20a-2 


AIR   SERVICE   MEDICAL   MANUAL.  21 

within  a  few  days  after  the  arrival  of  the  medical  officer  the  units 
were  ready  for  work.  By  this  method  of  decentralization  the  ex- 
amination of  thousands  of  applicants  in  a  minimum  time  was  made 
possible.  Once  it  was  assured  that  those  charged  with  the  responsi- 
bility of  conducting  the  examination  were  fully  equipped  and  capable 
of  making  the  tests,  full  authoritj'  was  vested  in  the  medical  officer  in 
charge.  Thirty-two  military  units,  later  established  in  the  divisional 
camps  of  the  United  States,  attended  to  the  examinations  of  the  en- 
listed applicants  for  air  training.  By  far  the  majority  of  applicants 
were  civilians,  however,  and  the  35  original  units  in  the  cities,  each 
examining  from  10  to  60  applicants  a  day,  soon  provided  the  thou- 
sands of  men  required. 

Attention  should  be  drawn  to  the  contribution  to  the  Government 
war  work  represented  by  the  vast  amount  of  professional  service 
rendered  without  pay  by  the  civilian  members  of  these  units.  These 
civilian  consultants  included  many  of  the  foremost  specialists  of  the 
United  States ;  were  the  services  rendered  by  them  to  be  represented 
in  terms  of  Liberty  bonds,  the  sum  total  would  constitute  a  verj- 
respectable  loan  without  interest.  It  is  worthy  of  special  mention 
that  in  addition  to  the  routine  examining  work  of  the  units,  the 
members  performed  many  hundreds  of  surgical  operations  enabling 
the  applicants  to  qualify  physically  for  this  service,  without  cost 
either  to  the  applicant  or  to  the  Government. 

A  public  meeting  was  held  in  each  city  under  the  auspices  of  the 
medical  profession  of  that  city.  The  mere  establisliment  of  the  units 
was  by  no  means  all  that  was  accomplished  by  the  work  of  the  Medi- 
cal Department.  Throughout  the  United  States  there  was  no  lack  of 
interest  on  the  part  of  the  young  men  of  the  country  to  enter  the 
flying  service.  There  was,  however,  a  striking  need  for  authoritative 
information  regarding  the  Aviation  Service  and  how  to  go  about 
getting  into  it.  A  by-product  of  the  establishment  of  the  units  was 
the  stimulation  in  each  city  of  large  public  interest  in  this  branch  of 
the  service.  In  one  city  after  the  meeting  95  men  expressed  their 
desire  to  enter  this  service. 

In  the  rush  of  events  after  our  entrance  into  the  war  not  only  was 
there  a  lack  of  information  regarding  Air  Service,  but  there  was  a 
considerable  amount  of  misinformation,  most  probabh'  attribut- 
able to  German  propaganda.  Throughout  the  country  was  spread 
the  information  that  the  average  life  of  an  aviator  was  only  a  few 
hours  of  actual  service.  Parents  were  given  to  believe  that  their 
sons  were  being  taken  for  an  almost  immediate  and  inevitable  sacri- 
fice. Furthermore,  there  was  not  a  citv  in  the  United  States  in  which 
it  was  not  firmly  believed  by  the  public  that  the  much-discussed 
medical  examination  of  an  aviator  was  a  form  of  refined  torture. 
One  story  was  that  of  the  "needle  test."    This  mythical  examination 


22  AIR   SERVICE   MEDICAL   MANUAL. 

was  supposed  to  consist  of  placing  a  needle  between  the  candidate's 
forefinger  and  thumb,  blindfolding  him,  then  shooting  off  a  pistol 
behind  his  ear.  The  examiner  would  then  note  whether,  due  to  his 
supposed  lack  of  nerve,  the  applicant  had  pushed  the  needle  through 
his  finger.  Another  much-rumored  test  was  described  as  follows: 
When  the  applicant  least  expected  it  he  would  be  hit  over  the  head 
with  a  mallet,  and  if  he  regained  consciousness  within  15  seconds  he 
was  qualified  as  being  of  the  stuff  of  which  aviators  are  made.  It 
was  the  medical  officer  who  could  supply  the  needed  information 
and  also  demonstrate  the  utter  nonsense  of  this  prevailing  misinfor- 
mation. In  this  way  parents  were  assured  by  the  Surgeon  General 
that  their  sons  were  put  through  only  an  ordinary  physical  exami- 
nation to  insure  their  fitness  for  the  service,  and  that  for  their  own 
protection  they  would  not  be  accepted  unless  physically  sound.  The 
mystery  of  the  examination  was  removed  by  actual  demonstration, 
aided  by  moving  pictures. 

At  these  public  meetings  were  gathered  those  of  the  medical  pro- 
fession and  general  public  who  were  interested  in  aviation.  The 
interest  aroused  within  the  medical  profession  by  the  work  of  the 
Physical  Examining  Units  also  resulted  in  bringing  into  the  Air 
Medical  Service  a  large  number  of  specialists  whose  training  in  the 
examination  of  aviators  fitted  them  later  for  a  larger  sphere  of  use- 
fulness in  the  care  of  the  flier. 


. '    >    )     >    ' 


>  >    ■>  >  '     '    J       >  1     )>'       5    ',  '       '      ^    >' 

)    ,  '      1  )      )    '   >      '     '  ^  ' 


l.''\<.'' 


'NIEUPORT/ 


e 


ovii^  '  *-V«*-fe-iV  "Ti:— 


^^ 


23a-2 


"LOENING   MONOPLANE.     HISPANO   SUISA   MOTOR. 


t       c    r       c    ,c « 


PL, 
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m 

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o 

o 


23a-4 


CHAPTER  III. 
CLASSIFICATION. 


The  flier,  who  through  good  training  has  become  perfect  in  his 
technique  and  who  through  proper  care  is  physically  fit,  is  not  neces- 
sarily fitted  for  all  types  of  air  activities.  When  the  present  war 
first  began,  there  were  but  few  airplanes  and  what  airplanes  existed 
were  used  for  all  kinds  of  work.  If  an  airplane  and  a  man  could 
stay  in  the  air,  they  were  used  for  any  service  which  an  emergency 
might  call  for.  On  one  day  the  pilot  might  be  asked  to  go  across 
the  lines  on  a  reconnaissance  mission  and  with  the  same  machine, 
which  was  very  limited  in  climbing  ability  and  speed,  he  would  be 
called  upon  the  following  day  to  go  into  the  air  to  fight. 

With  the  coming  of  improved  designs  and  the  more  skillful  manag- 
ing of  airplanes  by  fliers,  different  types  of  machines  have  become 
classified  into  special  groups  for  special  work.  The  flying  service  is 
now  highly  specialized.  Men  are  called  upon  to  perform  widely 
diversified  classes  of  work,  such  as  pursuit  or  scout  work,  recon- 
naissance, photography,  day  or  night  bombing,  artillery  observation, 
ynd  for  each  of  these  special  missions  the  pilot  is  provided  with  a  cer- 
tain type  of  plane  adapted  to  the  work  in  hand. 

Both  the  enemy  and  ourselves  divide  the  machines  used  for  service 
into  two  distinct  classes;  we  have  both  the  fighting  machines  which 
are  a  fast,  quick-climbing  type,  easily  and  quickly  maneuvered,  and 
heavier  machines  which  are  slower  in  action  and  capable  of  carrying 
almost  any  weight. 

It  is  easy  to  see  that  a  fast-climbing  machine  is  bound  to  carry 
the  pilot  to  greater  heights  than  the  slow,  weight-carrying  machines. 
Whereas  in  1915,  flying  rarely  exceeded  8,000  or  10,000  feet,  through 
improved  designs  scouts  of  to-day  climb  to  altitudes  even  as  high  as 
25,000  feet,  and  this  height  is  attained  in  a  very  short  space  of  time. 
The  nature  of  the  work  of  a  scout,  which  is  simply  hunting  out  the 
enemy  and  attacking  him,  also  necessitates  descents  from  high  alti- 
tudes at  tremendous  speed. 

Night  bombing  has  been  carried  out  at  altitudes  as  low  as  300 
feet.  Day  bombing,  in  order  not  to  reveal  the  objective  of  the  flight 
and  to  guard  against  concentrated  anti-aircraft  fire,  may  call  for 
flights  at  very  high  altitudes.     The  possible  necessity  of  attaining 

23 


24  AIB  SERVICE  MEDICAL  MANUAL. 

sucli  altitudes  presents  a  nice  problem  when  we  consider  the  weight 
of  bombs  which  must  be  carried,  together  with  the  protective  equip- 
ment with  which  the  plane  must  be  loaded.  Reconnaissance  ma- 
chines rarely  get  to  high  altitudes  owing  to  the  necessity  for  more  or 
less  close  observation  of  the  ground,  and  machines  doing  this  work 
must  accomplish  very  low  flying  even  in  the  face  of  highl}^  concen- 
trated anti-aircraft  fire  and  enemy  activity  in  order  to  fulfill  their 
mission.  Machines  cooperating  with  the  artillery  which  have  to 
make  range  corrections  for  batteries  do  not  often  work  above  6,000 
or  8,000  feet.  From  this  we  can  see  that  the  machines  doing  the  types 
of  work  just  mentioned,  except  day  bombing,  fly  very  much  lower 
than  the  pursuit  or  scout  planes.  With  their  capacity  for  carrying 
a  larger  amount  of  fuel,  they  can  remain  in  the  air  for  very  long 
periods.  When  a  long  trip  is  to  be  made,  such  as  a  bombing  raid  far 
into  the  enemy  country,  at  least  four  or  five  hours  must  elapse  and 
the  pilot  is  apt  to  be  fatigued  to  the  limit  of  his  endurance.  Espe- 
cially is  this  the  case  in  cold  weather  and  under  the  long  strain  of 
an  extended  flight  encountering  anti-aircraft  fire  and  enemy  planes. 

Pilots  of  scout  machines,  on  the  contrary,  owing  to  the  speed  and 
climbing  abilitj^  possessed  by  planes  built  for  this  type  of  work,  never 
stay  in  the  air  much  over  two  and  one-half  or  three  hours  on  account 
of  being  unable  to  load  up  their  machines  with  more  than  a  moderate 
weight  of  fuel.  But  they  have  to  go  to  tremendous  heights,  they  have 
to  change  those  heights  very  quickly  and  very  often,  and  they  are 
subject  to  quick  changes  of  temperature  as  well  as  sudden  variations 
in  oxygen  content  of  the  air. 

In  view  of  these  facts  the  Air  Medical  Service  realized  the  im- 
portance from  a  purely  military  standpoint  of  careful  classification 
of  fliers.  The  work  of  the  Medical  Research  Laboratory  has  demon- 
strated that  of  each  100  carefully  selected  fliers  only  61  are  physically 
and  mentally  capable  of  attaining  an  altitude  of  over  20,000  feet 
with  safety;  25  out  of  each  100  are  physically  and  mentally  unsafe 
at  altitudes  above  15,000  feet;  and  14  out  of  each  100  are  physically 
and  mentally  unsafe  at  altitudes  above  8,000  feet.  Or  that  61  of 
the  100  are  fit  for  any  type  of  air  work;  that  25  may  do  bombing; 
that  14  should  be  limited  to  reconnaissance  or  night  bombing.  Such 
classification  of  pilots  for  specific  duties  constitutes  a  new  factor  of 
conservation  and  safety  to  our  forces. 

The  feature  of  knowing  the  limitations  of  a  valuable  man  spell 
increased  efficiency. 

Just  as  the  pilot  is  provided  with  a  certain  type  of  plane  adapted 
to  the  work  in  hand,  so  the  plane  must  be  provided  with  a  pilot 
adapted  to  the  work  in  hand. 

It  is  true  that  in  the  absence  of  a  pilot  physically  and  mentally 
adapted  for  high-altitude  work  it  is  possible  to  use  one  who  is 


AIR  SERVICE   MEDICAL  MANUAL.  25 

adapted  only  for  low-altitude  work  by  equipping  him  with  an 
apparatus  to  supply  oxygen  according  to  his  needs.  Supplying 
oxygen  to  fliers  has  been  a  subject  of  much  experiment  and  study 
during  the  past  two  years  both  by  the  enemy  and  by  the  allies. 
The  British  have  used  an  oxygen  apparatus  of  satisfactory  type  for 
two  years — the  Dreyer  Apparatus.  This  type  of  apparatus  is  being 
produced  in  the  United  States  in  increasingly  large  numbers,  and  at 
the  same  time  modifications  and  improvements  are  being  constantly 
made.  In  the  very  nature  of  things,  however,  it  is  impossible  to  count 
upon  adequate  and  ready-to-serve  oxygen  supply  for  each  aviator  in 
each  machine  which  emergency  may  send  into  high  altitude.  Until 
the  final  absolute  perfection  of  oxygen  apparatus  for  the  flier  and  the 
equipping  of  each  high-altitude  plane  has  been  accomplished,  cogni- 
zance must  be  taken  of  altitude  rating  of  the  flier  in  "  selecting  the 
man  for  the  job." 

Physiologic  studies  on  men  undertaking  to  live  at  high  altitude, 
such  as  Pike's  Peak,  have  proven  that  a  very  complex  series  of 
changes  occur  before  their  bodies  become  able  to  live  normally 
with  less  oxygen.  This  is  acclimatization,  and  this  occurs  m  the 
man  living  on  Pike's  Peak,  but  not  in  the  aviator  who  alternates 
constantly  between  high  and  low  altitudes. 

The  flier  must  undergo  abrupt  changes  in  atmospheric  pressure 
and  oxygen  supply.  Atmospheric  pressure  plays  a  very  unimpor- 
tant role ;  the  whole  problem  resolves  itself  into  a  deprivation  of  the 
normal  oxygen  supply.  The  fact  that  there  is  "  oxygen -want "  at 
high  altitudes  suggested  that  any  piece  of  apparatus  that  would 
permit  the  breathing  of  a  reduced  amount  of  oxygen  could  be  used 
to  test  the  ability  of  men  to  withstand  high  altitudes.  The  Flack 
bag  was  the  prototype  of  the  rebreathing  apparatus  which  has  been 
developed  in  the  Medical  Research  Laboratory  and  perfected  for  such 
tests.  By  means  of  this  apparatus  the  aviator  rebreathes  air  con- 
fined in  a  tank,  from  which  he  gradually  consumes  the  oxygen.  As 
the  percentage  of  oxygen  decreases  the  aviator,  in  effect,  is  slowly 
ascending  to  higher  altitudes.  In  the  course  of  25  to  30  minutes  he 
lowers  the  oxygen  content  of  the  air  in  this  tank  to  8  or  7  per  cent, 
which  is  equivalent  to  attaining  altitudes  of  25,000  to  28,000  feet. 

Another  method  of  attaining  the  same  result  is  by  means  of  the 
diluting  apparatus,  which  supplies  directly  to  a  mask  over  the  face 
whatever  proportions  are  desired  for  a  mixture  of  air  and  nitrogen. 
All  of  these  tests  have  been  standardized  and  confirmed  by  the  low- 
pressure  tank,  in  which  the  air  is  rarefied  to  correspond  to  any  given 

altitude. 

By  a  comparison  of  the  percentage  of  oxygen  to  which  the  aviator 
succumbs  when  on  the  low-oxygen  tests  it  is  possible  to  determine 
precisely  the  altitude  at  which  the  aviator  would  fail  were  he  in  the 


26  AIR   SERVICE   MEDICAL   MANUAL. 

air.  This  determination  is  made  on  the  gi"ound,  without  danger 
either  to  the  aviator  or  to  his  machine,  and  has  been  taken  as  the 
basis  for  the  classification  of  aviators  now  in  use  by  the  Medical 
Eesearch  Laboratories. 

It  may  be  noted  that  these  tests  of  the  ability  of  an  aviator  to 
withstand  oxygen  reduction  could  not  be  made  safely  in  the  air,  as 
the  effects  of  oxygen-want  are  insidious  and  often  the  aviator  suc- 
cumbs very  suddenly  and  completely  when  his  limit  is  reached. 

The  effect  of  low  oxygen  upon  the  mental  processes  of  the  aviator 
varies  greatly  in  the  individual.  The  aviator  usually  becomes  men- 
tally inefficient  at  an  altitude  at  which  there  is  as  yet  no  serious  fail- 
ure of  his  vital  bodily  functions.  If  he  were  sent  to  an  altitude 
which  his  heart  could  safely  stand,  his  efficiency  would  nevertheless 
suffer  because  his  brain  is  not  acting  properly.  By  simple  tests  of 
mental  alertness  during  rebreathing  it  is  easy  to  determine  that  one 
flier  becomes  mentally  inefficient  at  15,000  feet,  in  sharp  contrast  to 
another  aviator  who  has  his  full  mental  powers  up  to  and  beyond  an 
altitude  of  25,000  feet. 

Low  ox3^gen  has  a  marked  effect  upon  vision.  Oxygen-want  ex- 
aggerates to  a  marked  degree  any  existing  defect  of  the  eyes.  In 
many  young  healthy  men  the  rebreathing  tests  made  manifest  eye 
defects  which  may  have  eluded  detection  by  the  most  expert  exami- 
nation. Crash  reports  have  demonstrated  that  a  large  proportion 
is  due  to  such  eye  defects.  Again,  in  night  flying  it  is  most  impor- 
tant that  the  flier  shall  be  able  "to  see  well  in  the  dark."  Many 
aviators  are  able  to  fly  well  without  any  difficulty  in  the  daytime,  but 
not  at  night.  Laboratory  tests  determine  definitely  which  individ- 
uals possess  the  ability  to  see  well  at  night. 

"  Stunting "  is  essentially  an  internal-ear  problem.  During  and 
after  rapid  turnings  the  flier's  brain  is  receiving  impulses  from  his 
semicircular  canals.  Nothing  can  control  or  alter  the  sending  or 
receiving  of  these  impulses.  These  imj^ulses  produce  sensations  of 
motion.  Fliers  vary  greatly  in  their  ability  to  interpret  correctly 
the  significance  of  these  impulses.  Experience  alone  enables  the 
aviator  to  familiarize  himself  with  the  meaning  of  these  impulses; 
those  who  develop  the  greatest  ability  in  this  respect  naturally  fall 
into  the  scout-pursuit  class.  Those  who,  in  spite  of  training,  are  still 
disturbed  or  bewildered  by  stunting  should  be  reserved  exclusively 
for  straight  flying,  such  as  bombing  and  photography.  Again,  the 
peculiar  demands  of  night  flying,  reducing,  as  it  does,  at  times  to 
the  vanishing  point,  information  coming  from  the  eyes,  require  a 
type  of  flier  who  possesses  the  keenest  ear  sense  for  the  detection  of 
movement. 

The  rebreathing  test  is  also  very  valuable  in  determining  staleness 
in  aviators.    As  staleness  is  caused  by  frequent  exposure  to  high 


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26a-4 


VERTICAL   BANK.     SIDE   SLIPPING— 2,000   FEET   IN    THE   AIR. 
Poor  balancing  ability  can  thus  endanger  pilot  an!  maehine. 


AIR  SERVICE   MEDICAL   MANUAL. 


27 


I 


THE  CHASE. 


™1 ^.,1-1       li. 


(      •■        f     r       I 


28  AIE  SERVICE   MEDICAL  MANUAL. 

altitudes,  evidence  of  this  is  easily  obtained  by  means  of  the  rebreath- 
ing  machine.  Where  originally  a  flier  was  able  to  tolerate  an  alti- 
tude of  20,000  feet  or  more  before  showing  certain  symptoms  of  stale- 
ness,  after  flying  for  100  hours  or  more,  it  is  frequently  found  in  re- 
examination by  means  of  the  rebreather  that  he  is  stale  and  is  unable 
to  tolerate  the  oxygen  reduction  equivalent  to  10,000  feet.  Incipient 
cases  of  staleness  are  thus  easily  detected.  The  detection  of  the  early 
cases  of  staleness  is  of  greatest  importance  in  that  it  makes  it  possible 
to  ground  a  man  for  a  certain  period  and  thus  enable  him  to  recover 
entirely,  whereas  if  this  condition  is  not  diagnosed  early  it  will  pro- 
gress until  a  point  is  reached  where  it  is  impossible  for  the  aviator 
to  "  come  back  "  and  his  services  as  a  flier  are  thus  lost  to  the  country. 
^Vhen  the  staleness  becomes  marked  the  aviator  is  very  liable  to  faint 
in  the  air,  thus  losing  his  life  and  wrecking  his  machine.  By  periodi- 
cally examining  aviators  the  first  signs  of  staleness  will  be  detected 
early  and  measures  can  be  taken  to  conserve  the  efficiency  of  those 
who  would  otherwise  be  inevitably  lost  to  the  service. 


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CHAPTER  IV. 
THE  FLIGHT  SURGEON. 


The  Flight  Surgeon  constitutes  the  ultimate  "answer  "  to  the  main- 
tenance problem  of  the  Air  Medical  Service. 

In  the  foregoing  chapters  has  been  presented  the  work  of  the  selec- 
tion of  the  aviator  and  of  the  classification  of  the  aviator.  The  Air 
Medical  Service,  however,  does  not  end  here.  It  is  all  very  well  to 
have  chosen  with  great  care  those  hand-picked  men  who  constitutt 
our  Air  Force  and,  thanks  to  the  enormous  number  of  applicants,  to 
have  adhered  to  the  highest  standards  in  their  selection.  It  is  all 
very  well  to  have  medical  specialists  classifying  fliers  and  deter- 
mining their  peculiar  fitness  for  special  branches  of  aerial  activity. 
This,  however,  by  no  means  marks  the  limit  of  usefulness  of  the 
Air  Medical  Service.  The  one  immediate  need  of  the  military  avi- 
ator in  all  the  services  of  the  world  is  an  organization  for  his  up- 
keep and  care  in  actual  service.  After  two  and  one-half  years  ol 
bitter  experience  it  was  gradually  borne  in  upon  the  allies  that  at 
the  end  of  a  certain  amount  of  continuous  service  the  flier  begins  to 
show  unmistakable  signs  of  deterioration,  and  the  economical  thing 
to  do  is  to  relieve  him  temporarily  from  active  flying.  This  was  a 
new  thought  in  aviation.  Up  to  that  time  it  had  been  the  practice 
to  keep  the  flier  at  it  until  he  broke.  His  breaking  was  signalized 
sometimes  by  simple  failure  to  return  from  behind  the  enemy  lines; 
sometimes  by  becoming  mentally  and  nervously  so  exhausted  as  to 
be  of  absolutely  no  use ;  at  other  times  becoming  so  physically  worn 
out  that  even  the  casual  observer  would  recognize  his  unfitness  for 
service. 

The  old  method  was  to  get  as  much  out  of  a  flier  as  possible,  then 
discard  him  as  useless  for  further  air  service.  The  alumni  of  this 
old  school,  although  not  all  present,  because  of  the  graduation  of 
so  many  behind  the  enemy  lines,  are  now  represented  by  the  hun- 
dreds of  "  washed  out "  fliers  from  the  Italian,  French,  and  British 
services  that  one  meets  in  various  ground  activities  in  the  flying 
schools  of  America  and  Europe. 

Many  of  these  are  unnecessarily  wasted.  Their  loss  to  active  serv- 
ice could  have  been  materially  reduced  by  means  of  competent  medi- 
cal officers  who,  recognizing  the  early  beginnings  of  deterioration, 

29 


30  AIE   SERVICE   MEDICAL  MANUAL. 

could  have  taken  them  off  in  time  to  permit  full  recuperation  and 
restoration  to  active  flying. 

It  is  easy  to  sum  up  the  various  means  by  which  a  flier's  usefulness 
may  be  terminated.     They  are  exactly  three : 

(1)  The  Hun. 

(2)  Failure  of  the  engine  or  plane. 

(3)  Failure  of  the  flier  himself. 

While  it  is  not  possible  to  arrive  at  exact  percentages,  estimates 
based  upon  information  from  every  source  in  Italy,  France,  and 
Great  Britain,  interviews  with  commanding  officers  and  medical  ex- 
perts in  all  the  flying  centers  and  at  the  various  fronts,  indicate  that 
not  2  per  cent  of  the  fliers  lost  to  active  service  are  put  out  by  the 
Hun.  Failures  of  the  airship  are,  at  the  present  time,  responsible  for 
very  limited  losses  to  the  service,  thanks  to  the  inspections  to  which 
they  are  constantly  subjected.  Two  years  ago  this  statement  would 
not  have  been  true;  the  mechanical  genius  of  the  world  has  been 
applied  to  make  the  airplane  safer  and  with  such  effect  that  it  hap- 
pens onl^'  rarely  that  the  flier  becomes  useless  through  the  fault  of 
the  ship.  Statements  from  all  sources  agree  that  of  the  total  number 
of  fliers  permanently  out  of  flying  service,  not  over  8  per  cent  have 
been  rendered  unserviceable  because  of  mechanical  shortcomings  of 
plane  or  engine.  When  it  has  been  stated  that  2  per  cent  of  the  total 
number  of  fliers  incapacitated  for  further  air  service  are  put  out  by 
the  Hun,  and  8  per  cent  because  of  mechanical  shortcomings  of  the 
airplane,  the  remaining  90  per  cent  looms  large,  when  it  is  realized 
that  this  proportion  represents  troubles  in  the  flier  himself. 

After  assembling  all  possible  information,  subjecting  it  to  careful 
study  by  competent  experts  and  reaching  definite  conclusions,  the 
material  so  obtained  has  been  put  into  shape  for  further  training  of 
a  corps  of  medical  officers  who  have  had  opportunity  to  become 
familiar  with  the  Air  Medical  Service  by  actual  experience  in  the 
examination  of  applicants,  the  post-surgeon  work  in  flying  fields, 
and  the  reexamination  of  fliers.  This  is  the  epitome  of  the  develop- 
ment of  the  flight  surgeon  idea.  Through  such  a  corps  of  officers, 
established  in  the  various  flying  fields,  practical  application  can  be 
made  of  means  and  methods  devised  for  the  better  maintenance  of 
the  physical  efficiency  of  the  flier.  Just  as  the  Medical  Department 
of  the  Army  has  been  able  to  wipe  out  typhoid  fever,  and  made  it 
possible  to  construct  the  Panama  Canal  by  the  elimination  of  yellow 
fever,  so  the  Air  Medical  Service  is  destined  to  serve  by  prevention 
of  the  crash  rather  than  by  "  picking  up  the  pieces  "  afterwards. 

Medical  officers  of  the  various  air  services  had  observed  that  more 
than  half  of  the  injuries  sustained  in  crashes  were  caused  by  the 
aviator  striking  his  head  against  the  cowl.  It  was  suggested  that 
the  cowl  be  cut  out  so  as  to  give  8  inches  more  room  in  front.    A 


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43 


30a-2 


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30a-7 


EXAMINATION   OF   FLIER. 


MAJ.   HITCHCOCK  l.N    I'lLUTS   SKAT. 


30a-9 


r    r      <■    ^  f  ' 


I 


AIR   SEEVICE   MEDICAL  MANUAL. 


31 


DECOYED. 


32  AIE  SERVICE  MEDICAL  MANUAL. 

report  just  received  from  the  Royal  Air  Force,  Canada,  states  that 
since  this  change  in  the  cowl  has  been  made  these  head  injuries  have 
been  practically  eliminated.  Another  suggestion  was  to  lash  the 
safety  belt  to  the  machine  by  a  simple  rubber  shock  absorber;  the 
same  report  states  that  since  this  has  been  done,  the  number  and 
extent  of  injuries  to  the  upper  abdomen  and  ribs  have  been  de- 
cidedly reduced.  The  problem,  of  protecting  the  flier  against  the 
extreme  cold  of  high  altitudes  in  winter  was  solved  by  designing 
electrically  warmed  clothing,  thereby  enabling  him  to  continue  his 
flying  under  conditions,  which,  up  to  that  time,  had  rendered  it 
impossible.  The  problem  of  enabling  a  flier  to  withstand  the  glare 
of  reflected  sunlight  above  cloud  banks  and  to  enable  him  to  pierce 
camouflage  was  solved  by  furnishing  him  with  the  "  Noviol "  type 
of  goggles.  During  the  first  two  and  one-half  years  of  the  war  no 
attempt  was  made  to  compensate  the  flier  for  his  lack  of  sufficient 
oxygen  in  high-altitude  work.  There  is  one  British  squadron  which 
has  used  the  Dreyer  oxygen  apparatus  since  January,  1917 ;  a  recent 
report  from  the  British  front  states  that  this  squadron  has  been 
performing  six  times  the  amount  of  work  of  any  other  similar 
squadron  which  is  not  supplied  with  oxygen. 

The  above  are  examples  of  what  has  already  been  accomplished 
towards  reducing  this  "  90  per  cent;"  many  other  methods  are  now 
being  developed.  Within  the  past  few  months  has  been  perfected 
an  apparatus  whereby  cadets  may  acquire  flying  experience  and 
training  without  leaving  the  ground.*  This  machine  is  a  modifica- 
tion of  the  old-fashioned  universal  joint,  composed  of  three  con- 
centric rings  so  pivoted  together  as  to  permit  the  fuselage,  which  is 
pivoted  within  the  innermost  ring,  to  be  put  through  every  possible 
evolution  to  be  experienced  in  actual  flying.  This  apparatus  is 
practically  an  airplane  in  every  respect.  The  cadet  sits  in  the  fuse- 
lage and  by  means  of  the  joystick  and  rudder  puts  himself  through 
practically  all  the  evolutions  which  he  is  later  to  experience  in  the 
air.  An  analysis  of  the  "  crash  reports  "  has  shown  that  a  remarkably 
large  number  are  solely  due  to  a  failure  to  come  out  of  the  spinning 
nose  dive  or  tight  spiral.  The  only  reason  that  the  cadet  has  failed  to 
come  out  of  these  maneuvers  is  that  he  had  not  yet  become  accus- 
tomed to  these  unusual  movements.  These  evolutions  stimulate  the 
internal  ears  which  send  nerve-impulses  to  the  brain.  The  individual 
has  no  control  over  these  impulses;  the  only  thing  he  can  do  is  to 
learn  the  significance  of  these  impulses  by  experience.  The  problem 
is  extremely  simple.  All  that  is  needed  is  that  every  cadet  shall 
"  fly  "  the  apparatus  day  after  day  until  he  is  entirely  familiar  with 
these  new  sensations.  Any  mistake  that  he  makes  causes  him  no 
harm,  because  he  never  leaves  the  ground.    He  is  then  prepared  to 

♦The  Ruggles  Orientator. 


kl<;(;li:s  uuientatok." 
(Supplied  througli  tbe  courtesy  of  the  Naval  Consulting  Board.) 


"  RUGGLES   ORIENTATOR." 

(Supplied  through  the  courtesy  of  the  Naval  Consulting  Board.) 


132-2 


■  KUGGLES    OIUENTATOIt." 
(Supplied  throuffh  the  courtesy  of  tlif  Naval  Consulting  Board.) 


<    t  c       r  ' 


"  RUGGLES    ORIENTATOR." 
(Supplied  through  the  courtfsy  of  the  Naval  Consulting  Board.) 


132-4 


"RUGGLES  ORIENTATOR." 
(Supplied  through  the  courtesy  of  the  Naval  Consu  ting  Board.) 


THE  SIXTH  SENSE. 


(Diagrammatic.) 

THE  THREE  SEMICIRCULAR  TUBES  CONSTITUTE  THE 
'•MOTION-SENSING"  ORGAN. 


The  internal  ear  or  labyrinth  consists  of  a  bony  and  a  membraneous  part,  the  latter  contained  in  the 
former.  The  bony  labyrinth  is  composed  ofthe  vestibule,  the  semicircular  canals,  and  the  cochlea. 
These  three  canals  constitute  what  is  known  as  the  static  labyrinth.  The  bony  canals  contain  the  mem- 
branous canil,  an  1  the  membranous  canil,  in  turn,  contains  the  endolymph,  which  is  a  fluid  that 
fills  the  membraneous  canal.  This  posterior  part  of  the  internal  ear  is  constructed  .solely  for  the  detec- 
tion of  movement,  anl  constitutes  the  special  sense  organ  of  "motion-sensing".  Man  is  acquainted 
■with  movement  through  this  organ  by  the  flowing  of  the  endolymph  within  the  canals. 


HUMAN  TEMPORAL  BONE,  NATURAL  SIZE,  INTERNAL  OR  BRAIN  SURFACE;  SHOW- 
ING INTERNAL  EAR  CONSISTING  OF  COCHLEA  (a),  THE  SUPERIOR  AND  POSTERIOR 
SEMICIRCULAR  CANALS  (b  and  e)  MHICH  HAVE  BEEN  EXPOSED  BY  REMOVING 
PORTION   OF   THE   BONE. 

(Actual  photograph.) 
32a-6 


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32a- 


83 

AIK  SERVICE   MEDICAL  MANUAL. 

.■      "  in  the  air     Flying  training  by  this  "  ground 
..ndertake  "  stunting      n  the  ai^       y    »^  ^^^^  ^^^^^^.^^^  supervision 

training  flying  apparatus  ■^'^""'"J  j^    g;  j.^  surgeon. 

of  the  ollicer  in  charge  of  flying  and  the  mg  ^  _^^^^^^  ^^  g^^^g 

Anotlier  method  of  educating  the  «.det  ^     J  ^^^  ^^^^,^ 

calisthenics.     By  daily  '— ^  »i~on  becomes  accustomed 

-""  "\""'  .:,rtr:t    :^t    w, -111  h;  had  previously  been  un- 
to  positions  ana  n.o\uiit-"" 

accustomed.  .         overseas  means  an  expendi- 

men  we  '-^f"^^^!*^*  -as  represented  by  his  training  m  the 
ture  of  upwards  f .  ^^O'""^"  ..^". 'J,„o,   by  the  employment  of  air- 
ground  school  and  ni  the  fl>;"8    *;°'' J  ^eir  upkeep,  as  well  as 
planes  and  the  necessary  n^"^';^;  ^^         ,„d  transportation- 
his  personal  expense  t^  the  ^''^""^^^t^rian  standpoint,  there  is  a 
„e  realize  that,  apart  f™"  ^-^j^fj^p,,  care  of  this  tremendous 
purely  military  aspect  wh^h  ^^^^'^„m,  buman  material 
financial  investment.     This  sa^  mg  ,oviding   a   specially 

and  money   can  be  »<:™'"l'l^^^>'^'^,.™f,Ss„r  to  the  Commanding 
ii-ained  medical  "f -^  ^'^^  ^.^  of "  — ing  the  mental  and 

'^  '^: m^^if^bif  ;SL,  the  general  ^«  .nth^^ed  th^s^n^^ .ade 
in  the  tables  of  organization,  the     W  ^ur  ^^^  ^^.^.^^^ 

nr;S  ro^S  t^  ^StlL  nmted  state,  and  the 
others  for  overseas  service  »«  M«lcd.  ^  ^^^  ^^  ^^^■^^. 

Specifically,  "the  duty  of  *«/ ^f ^Is  and  squadron  groups, 
to  the  Commanding  Oftcer  of  ^^'"8  f™"  f^,,^ao.n  of  independent 
Although  under  the  Post  S-f--,^- j^f  a  ators  or  cadets.  Sub- 
initiative  in  all  questions  of  Aj^^S  6  ^^^  ,.,  ^  expected  to  m- 
ject  to  the  approval  of  the  <;'7'"f " '"'"^^ation,  and  temporary  ex- 
stitute  snch  measures  as  P»™''^^f  ^^^''^s*!^-  «»  takes  sick  call 
cuse  from  duty,  as  may  seem  to  ^im  a^.isao  ^^  ^^^^ 

for  aviators  and  -'j^ts  aiul  .-coX«     *^^^^ 

excused  from  duty.    He  w HI  MSit  snc  ^^  physician 

at  the  post  and  consult  with  ^^\^l^''^^^^^,,^,„„rmev<.^xo.min^- 
vegarding  them.  From  time  '« '""\^  ,7  J^Xrexaminations  as  he 
tions  of  aviators  and  cadets;  ako    «  h  spec  ^^^^.^^^^  ^^  ^^^ 

,  may  deem  advisable,  being  ^f'^^fj^^'^^  ^^^  ,i^,  ;„  as  close  touch 

^         Branch  Medical  Eesearch  I^*°™"'3'-.„„\7is  consistent  with  the 
with  the  fliers  and  cadets  at  his  station  as 

conditions." 

89120—18 3 


34  AIR  SERVICE   MEDICAL  MANUAL. 

"  Each  Flight  Surgeon  will  have  as  an  assistant  a  Physical  Director, 
whose  duty  is  to  supervise  such  recreation  and  physical  trainiug  of 
aviators  and  cadets  as  is  considered  necessary.  He  will  live  and  mess 
with  the  cadets,  keep  as  closely  in  touch  with  them  as  possible,  stud}' 
their  habits,  temperaments,  and  physical  fitness,  and  advise  the 
Flight  Surgeon  in  all  matters  regarding  these  points." 

So  much  for  the  official  routine ;  it  needs  but  a  glance  at  the  many 
activities  suggested  to  realize  that  back  of  this  order  was  a  great 
need — the  daily  care  and  watchfulness  over  the  aviator. 

The  medical  study  of  aviation  is  so  new  that  unless  a  medical 
officer  has  been  specially  trained  for  the  aviation  service  he  can  have 
no  idea  whatever  of  the  methods  of  making  diagnosis  of  the  ills 
peculiar  to  flying.  For  this  highly  specialized  phase  of  medical 
work  the  Flight  Surgeon  must  have  certain  special  qualifications. 
For  this  reason  the  greatest  care  has  been  exercised  in  the  selection  of 
each  Flight  Surgeon,  as  it  was  recognized  that  the  entire  success  of  the 
work  depended  upon  the  personality,  experience,  and  diagnostic  skill 
of  the  medical  officers  selected  for  this  special  duty. 

Ideal  material  for  Flight  Surgeons  became  available  when  a  large 
number  of  Plwsical  Examining  Units  completed  their  work.  Those 
medical  officers  were  chosen  who  had  had  large  experience  in  examin- 
ing hundreds  or  thousands  of  applicants  for  the  service.  From  this 
group  were  selected  those  whose  personality  was  such  that  they  could 
not  only  command  the  respect  but  the  confidence  of  the  individual 
aviator.  This  is  essential.  The  efficient  Flight  Surgeon  is  one  whose 
personality  is  such  that  the  cadet,  flying  officer,  or  aviator  at  the 
front,  feels  that  he  has,  in  his  Flight  Surgeon,  one  to  whom  he  can  go 
Avithout  restriction — in  the  same  spirit  with  which,  in  civilia)i  life, 
he  was  accustomed  to  consult  his  family  physician.  When  a  prospec- 
tive Flight  Surgeon  had  been  selected  for  his  exceptional  ability  and 
knowledge  of  the  special  diagnostic  tests,  and  for  his  personality,  he 
was  then  sent  to  the  Medical  Research  Laboratory  at  Mineola,  Long- 
Island,  where  he  received  intensive  training  in  those  special  tests  with 
which  he  had  not  yet  become  familiar  in  his  original  examining 
work. 

The  Flight  Surgeon  was  also  given  adequate  opportunity  to  acquire 
actual  flying  experience  both  at  Mineola  and  at  the  flying  fields. 
This  enabled  him  to  supplement  his  other  special  preparations  for 
his  own  peculiar  work  with  the  much  needed  first-hand  "  knowledge 
of  the  air."  Permission  has  been  granted  by  the  Director  of  Military 
Aeronautics  for  these  officers,  among  others,  to  take  regular  ground 
and  air  courses  of  instruction  in  flying,  and  many  of  the  Flight  Sur- 
geons have  already  (pialified  for  R.  M.  A.  Actual  flying  is  of  great 
value  as  an  additional  aid  in  rendering  the  Flight  Surgeon  better  able 


w 

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34a-3 


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34a-4 


^     'HJ)^"*      at      » 
»>  D       »       »    »  »i       » 


f  ",  »     ^    ),  , 


^ 

a 

^ 


POOL. 


BOWLING. 


34a-6 


1  c  t  t 
i  .  c  '  I 
<      t      <  ,      ' 


1       <     I  ' 


MAJ.  WM.  R.  REAM,  THE  FIRST  FLIGHT  SURGEON 
TO  BE  PUT  ON  FLYING  STATUS. 


MAJ.    REAM   IN    HIS   PLANE. 


34a-S 


AIR  SERVICE   MEDICAL  MANUAL. 


35 


to  realize  and  cope  with  the  peculiar  conditions  and  ills  incidental 
<"'^>  aviation. 

.t  the  Medical  Research  Laboratory  he  was  enabled  to  secure  all 
tile  up-to-the-minute  information  regarding  the  e3'e,  ear,  nose  and 
throat,  cardio-vascular,  physiologic,  psychiatric,  and  psychologic 
work.  Of  the  new  problems  taken  up  at  the  Medical  Research  Lab- 
oratory, studies  in  psychiatry  were  of  peculiar  importance.  No  Flight 
Surgeon  can  adequately  diagnose  an  aviator's  condition  Avho  has  not 
the  ability  to  determine  the  mental  condition  of  the  individual.  If 
ftn  aviator  is  having  sleepless  nights,  worr3dng  over  financial  problems, 
anxieties  regarding  the  wife  at  home  who  is  about  to  become  a  mother, 
or  other  anxieties  of  everyday  occurrence  in  human  life,  it  is  not  sur- 
prising if  we  find  that  he  is  not  in  fit  condition  to  fly.  It  has  been 
repeatedly  proven  that  if  the  aviator  who  has  Ijeen  flying  badly  under 
such  a  mental  handicap,  tells  his  troubles  to  an  intelligent  and  sympa- 
thetic listener,  he  is  almost  invariably  able  to  ''  get  hold  of  himself,'" 
after  which  he  goes  out  again  and  flies  well.  The  Medical  Research 
Laboratory  provides  instruction  in  all  these  essential  branches:  after 
a  course  of  four  or  five  weeks  of  such  intensive  instructions  the  Flight 
Surgeon  is  then  sent  to  work  among  the  aviators,  under  actual  service 
conditions. 

It  has  become  evident  during  the  past  nine  months  through  activi- 
ties of  nutritional  survey  parties  of  the  Food  Division,  Surgeon  Gen- 
eral's Office,  that  there  is  great  need  in  each  aviation  camp  for  a 
Nutrition  Officer.  Stated  in  the  briefest  terms  the  needs  for  his  serv- 
ices are  these : 

The  strain  on  the  flier — especially  the  mental  strain — is  great. 
He  is  very  susceptible  while  on  flying  duly  to  influences  that  would 
ordinarily  not  aft'ect  him  at  all.  To  reach  and  maintain  his  maximum 
efficiency  requires  his  being  in  the  best  ph3'sical  and  mental  condition. 
In  peace  times,  under  conditions  where  neither  life  and  death  nor 
great  ideals  are  at  stake,  a  "training  table"  is  maintained  for  club 
or  college  athletes.  This  is  done  because  it  is  recognized  that  im- 
proper feeding  may  reduce  a  man's  efficiency,  or  even  put  him  "  out  of 
the  running  "  in  a  contest  in  which  his  best  is  required  to  win.  In 
the  case  of  the  flier  w-e  are  concerned,  when  he  goes  up,  not  only  with 
questions  of  life  and  death  and  ideals,  but  with  the  fact  that  he,  more 
than  the  average  athlete,  depends  for  success  upon  clearness  of  mind, 
quickness  of  thought,  keenness  of  judgment.  All  these  are  mental 
faculties,  not  muscular.  The  nervous  system  is  more  highly  differ- 
entiated than  the  muscular  system,  and  by  reason  of  that  fact  more 
easily  upset  by  improper  food. 

For  the  highest  efficiency  of  the  flier  there  is  required  some  form 
of  training  table.  At  times  when  he  is  slightly  unfit,  with  headache, 
constipation,  etc.,  this  is  doubly  needed.    A  Nutrition  Officer  with 


36  AIE   SERVICE   MEDICAL  MANUAL. 

special  training  in  knowledge  of  food  values  should  supervise  the 
messes  of  all  students  and  officer  fliers  in  order  to  keep  up  the  effi- 
ciency of  the  fliers  and  prevent  as  far  as  possible  the  development 
of  digestive  ailments  of  even  minor  character.  But  in  addition  to 
this,  everj'  flier  who  develops  a  digestive  disorder  should  constitute 
a  special  problem  for  the  Nutrition  Officer  so  that  he  may  become 
"  fit  "  again  at  the  earliest  possible,  moment.  With  such  food  super- 
vision the  general  efficiency  of  the  fliers  can  be  raised  definitely,  the 
number  of  hours  per  month  that  these  men  are  fit  for  flying  duty 
increased,  and  finally  the  danger  to  both  life  and  equipment  of  the 
flier  greatly  reduced. 

With  expert  supervision  of  the  flier's  nutrition  and  exercise,  sup- 
plementing his  own  professional  knowledge  concerning  flying  and 
the  aviator,  the  Flight  Surgeon  neglects  nothing  of  a  practical  value 
which  can  be  used  in  maintaining  in  the  highest  degree  the  physical 
efficiency  of  the  Air  Fighting  Force. 

Without  exception  the  Commanding  Officers  of  the  aviation  fields 
have  welcomed  the  advent  of  the  Flight  Surgeon.  They  realize  the 
tremendous  responsibility  of  sending  a  man  into  the  air  who  may, 
at  the  time,  be  mentally  or  physically  unfit  for  flying.  No  Command- 
ing Officer  has,  for  the  sake  of  a  large  record,  ever  shown  a  tendency 
to  force  his  men  into  the  air.  From  a  military  standpoint  they  re- 
alize that  an  attempt  to  escape  duty  on  the  part  of  an  aviator  is  an 
altogether  different  matter  from  such  an  attempt  of  men  enlisted  in 
other  branches  of  the  service.  The  Commanding  Officer,  or  officers 
in  charge  of  flying,  who  are  constantly  observing  their  men  in  flight, 
sense  certain  transitory  changes  in  a  man's  condition  which  impair 
his  air  efficiency.  They  are  often  called  upon  to  ground  such  a  man 
or  relieve  him  from  duty.  It  is  not  to  be  wondered  at,  therefore, 
that  they  welcome  the  support  of  the  Flight  Surgeon  who  adds  a 
medical  knowledge  to  their  own,  which  after  all  is  based  upon  ex- 
perience alone.  The  Flight  Surgeon,  in  addition  to  maintaining  at 
the  highest  point  the  physical  efficiency  of  the  flying  force  of  'a 
command,  is  prepared  at  any  time  to  furnish  to  the  Conmianding  Offi- 
cer a  reliable  expert  opinion  as  to  each  individual's  mental  and  physi- 
cal fitness  for  flying  duty. 


I 


•...•  • 


•.* .  •  .  •       •  ••  •    •  !,•  *,  •  • 


INDEX. 


Page. 

Air  service,  policy  of  placing  worn-out  men  in 11, 29 

Air  superiority  held  by  Germans  during  early  stages  of  the  war 10 

Airplanes: 

Altitudes  attained  by 23 

Development  of,  among  the  allies,  a  story  of  sportsmanship 10 

Extraordinaiy  development  due  to  necessity  arising  from  actual  warfare. .  10 

Failures  of,  responsible  for  limited  losses 30 

Interest  in,  by  European  nations,  when  first  invented 10 

Losses  of,  responsibilities  for 30 

Progress  in  development  of 7, 10 

Realization  of  the  possibilities  of  the  airplane  as  a  factor  in  battle 10 

Altitudes,  liigh: 

Proportion  of  fliers  capable  of  attaining 24 

Rebreathing  apparatus  for  attaining 25 

Apparatus  for  acquiring  experience  and  training  without  leaving  the  ground ...  32 
Aviators: 

Altitudes  capable  of  attainment,  by 24 

Carelessness  in  selection  of,  in  early  stages  of  war 11 

Classification  of,  as  to  fitness  for  different  types  of  air  activities 14, 23 

Flier  at  the  front  safer  than  infantryman  in  trench 11 

Low  oxygen,  effect  of,  upon  mental  processes 26 

Low  oxygen,  effect  of,  upon  vision 26 

Ninety  per  cent  of  losses  due  to  physical  defects 30 

Oxygen,  apparatus  for  supplying 25 

Physical  fitness  of 13 

Proportion  of  fliers  capable  of  attaining  high  altitudes 24 

Selection  of,  method  of 17 

Study  of,  as  an  individual 13 

Though  physically  fit,  not  necessarily  fitted  for  all  types  of  air  acti\'ities. .  23 

Charts 8,  9, 18, 19, 27,  31 

Classification  as  to  fitness  of  fliers  for  different  types  of  air  acti\dties 14, 23 

Cowl,  change  in,  to  avoid  injuries  in  crashes 32 

Dreyer  oxygen  apparatus 32 

Electrically  warmed  clothing 32 

Examination,  physical,  of  applicants,  form  used 17 

Flight  Surgeon,  duty  of 14,  29, 33 

Goggles,  "  No\-iol "  type  of,  furnished 32 

Medical  units,  establishment  of,  for  examination  of  applicants 20 

Mental  processes,  effect  of  low  oxj^gen  upon 26 

Nutrition  officer,  duties  of 15, 35 

Oxygen: 

Apparatus  for  supplying 25 

Low,  effect  of,  upon  mental  processes 26 

Low,  effect  of,  upon  ATsion 26 

Physical  director,  duty  of 14, 34 

37 


38  INDEX. 

Physical  examinations:  Page. 

Medical  units  for  examination  of  applicants  established  in  35  cities 20 

Methods  of,  in  selection  of  fliers 17 

Form  used  in 17 

Uniform  tests  throughout  all  examining  units 20 

Shock  absorber  for  use  in  lashing  safety  belt  to  machine 32 

Staleness  in  aviators,  rebreathing  test  in  determining 26 

Stunt  flying 26 

Uniform  tests  throughout  all  physical  examining  units 20 

Vision,  effect  of  low  oxygen  upon 26 

Wright  biplane,  interest  in,  by  European  nations  when  first  invented 10 

o 


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THIS  BOOK  IS  DUE  ON  THE  LAST  DATE 
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WILL  INCREASE  TO  50  CENTS  ON  THE  FOURTH 
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